Earnings Call Transcript - TCMD Q1 2024

Operator, Operator

Welcome, ladies and gentlemen, to the First Quarter 2024 Earnings Conference Call for Tactile Medical. Please note that this conference call is being recorded and will be available on the company's website for replay shortly. I would now like to turn the call over to Sam Bentzinger from Gilmartin Group for a few introductory comments. Please go ahead.

Sam Bentzinger, Gilmartin Group

Good afternoon, and thank you for joining the call today. With me from Tactile's management team are Dan Reuvers, President and CEO; and Elaine Birkemeyer, CFO. Before we begin, I would like to remind everyone that our remarks and responses to your questions today may contain forward-looking statements that are based on the current expectations of management and involve inherent risks and uncertainties, which could cause actual results to differ materially from those indicated, including those identified in the Risk Factors section of our annual report on Form 10-K as well as our most recent 10-Q filing to be filed with the Securities and Exchange Commission. Such factors may be updated from time to time in our filings with the SEC, which are available on our website. We undertake no obligation to publicly update or revise our forward-looking statements as a result of new information, future events or otherwise. This call will also include references to certain financial measures that are not calculated in accordance with generally accepted accounting principles or GAAP. We generally refer to these as non-GAAP financial measures. Reconciliations of those non-GAAP financial measures to the most comparable measures calculated and presented in accordance with GAAP are available in the earnings press release on the Investor Relations portion of our website. With that, I'll now turn the call over to Dan.

Daniel Reuvers, President and CEO

Thanks, Sam, and welcome, everyone, to our first quarter 2024 earnings call. Let me start by providing a quick agenda for today's call. I'll begin with a high-level overview of our strong first quarter financial results and the key drivers of our sales performance, followed by some color on how we've advanced each one of our strategic priorities that we laid out in February. Elaine will then walk through our quarterly financial results in greater detail. And I'll conclude with a few final thoughts before we open the call up to questions. With that, let's turn to a review of our first quarter financial performance. Our total revenue grew 4% year-over-year to $61.1 million, in line with our expectations. We were pleased with this performance to start the year given our strong first quarter results last year and believe it provides a solid foundation to deliver on our 2024 operating plan. Looking at our revenue performance by product line. Lymphedema revenues increased 5% year-over-year to $52.3 million. And while our airway clearance revenues declined 4% year-over-year to $8.8 million, we demonstrated a second straight quarter of sequential improvement. Our lymphedema growth was in line with our expectations for the quarter, while sales of AffloVest were slightly ahead on a steeper year-over-year comp, reflecting broad-based growth among most of our DME partners and lending confidence for the rest of the year. Beyond our revenue performance, we also continued to gain momentum down the P&L, specifically with respect to a 100% increase in adjusted EBITDA versus prior year. Our cash balance reflected another strong finish as we benefited from significant progress with our collections working down our accounts receivable, a key element of our 2024 strategy to drive continued free cash flow generation while also deploying investments in our technology road map, which I'll expand upon shortly. With our financial highlights as a backdrop, I'd like to share a bit more about the operational progress we made in the first quarter. As we shared during our last update in February, we cited 3 key areas of focus for 2024: an investment in growing headcount and productivity within both our lymphedema and respiratory channels along with expanding our AffloVest DME participation. We also described a series of tech-related investments intended to improve our customers' prescribing experience as well as our own internal effectiveness. And finally, we described a next-generation lymphedema therapy platform as well as our commitment to conclude our head and neck study and share results near the end of the year. I'm pleased that we've moved every one of those initiatives forward in the first quarter, and we'll share more color on each. Beginning with our sales channels. From a headcount perspective, we ended the quarter with 269 field sales representatives, adding 15 since the beginning of 2024 and up approximately 9% in comparison to the 246 representatives that we had at the end of the first quarter of last year. These added reps came on later in the quarter, and we look forward to their increasing contributions in the second half of the year once they're fully trained. Productivity continued to advance among our legacy reps during the first quarter, specifically by continuing to focus on reducing the amount of time our reps spend on non-selling activities like in-home patient demos. As a reminder, our reps have historically devoted a significant portion of their time conducting payer-required in-home patient demos and obtaining the necessary documentation to complete orders and submit claims, a necessary task, but it clearly limits their time with prescribing clinicians. Our patient training staff is well equipped to introduce our therapies to patients and educate them on its use. Thus, we've been focused on assigning more of these home-based demos to them. This was a significant contributor to sales productivity gains last year as we started 2023 with the sales force performing the majority of these presales demos in the home and ramp to approximately 30% of them performed by our trainers by the end of last year. In the first quarter, we continued that momentum, completing 35% of in-home demos by trainers, allowing our reps to benefit from the added selling bandwidth. During the first quarter, we also continued to see a favorable response to our recently introduced products, particularly our Entre Plus system. With Entre serving as the entry-level treatment that many payers require the patient to try first, including Medicare, our focus on serving the patient wherever they enter the therapeutic funnel continues to pay dividends. We also saw a solid reception from our recently launched ComfortEase garments to treat lymphedema for upper extremities, bringing relief to even more breast and head and neck cancer survivors. Before shifting to an update on airway clearance, it's worth noting that we achieved our lymphedema results in the first quarter despite being among the many health care companies impacted by the Change Healthcare cybersecurity breach within United Healthcare's Optum branch that occurred earlier in the quarter. On February 21, we were notified of a cyber event at Change, a third-party provider of technology used to verify patients' benefits and bill for medical insurance claims that led them to disconnect certain IT systems and services with customers, including Tactile Medical and Brightree, our external billing provider. We've been using Change Healthcare for electronic verification of patient benefits, while our actual claims processing and billing is conducted using Brightree. Upon learning of the cyber event, our team acted swiftly to address these operational gaps, pivoting to a new partner within days to conduct electronic benefits verification. While Brightree was impacted by the cyber event, we again promptly found alternative ways to continue submitting claims, thereby further minimizing the impact on our patients, cash collections and our broader operations. I'm proud of the way our entire team swiftly responded to this situation and believe it reflects the leadership in place at Tactile. To have achieved our lymphedema growth this quarter with minimal disruption to both patients and our operations in the face of these unforeseen headwinds is a testament to our commitment to our tech-forward strategy and how nimble our organization has become. Now a few comments on our airway clearance progress. As I mentioned earlier, our first quarter airway clearance results were slightly better than we expected, thanks to the broad-based strength among most of our DME partners. In fact, excluding the one large DME affected by the PHE waiver that we've discussed earlier, collective revenue from all other DME customers increased over 20% in the first quarter as compared to the first quarter of 2023. With respect to the DME customer whose ordering was particularly affected by the PHE waiver, we were pleased to see shipments continue to stabilize in the first quarter. Over the long term, we continue to expect sustained growth from AffloVest, our airway clearance system, particularly following the anniversary of the PHE waiver expiration this May when we anticipate the affected distributor laps the issue and no longer serves as a headwind to our growth. We remain focused this year, not only on expanding our AffloVest sales specialist count, but also onboarding additional DMEs and demonstrating how AffloVest can be a valuable new offering for their large base of existing complex respiratory patients. To that end, we made further investments during the first quarter in our sales specialist staff, increasing the number of airway clearance reps to 17 from just 12 a year ago. These investments in our sales team will help increase our coverage of existing DME customers as we educate, train and support their reps on bronchiectasis and the role of AffloVest in their care as well as to enlist even more branches to make AffloVest part of their treatment arsenal. Turning to an update on another of our key focus areas for 2024. A number of our tech-related investments advanced in the quarter. As we shared during our February update, we're making strategic technology investments this year while still demonstrating leverage in our P&L, and they're progressing well. A portion of these investments involve enhancing various back-office processes, including our method of verifying patient benefits. As I mentioned earlier, we've recently transitioned to a new, more efficient electronic method of verifying benefits intended to accelerate order processing. Separately, we've begun piloting an e-prescribing platform to streamline how we collect and exchange patient medical records with payers during the prescription process. This is intended to make documentation and authorization easier for health care providers as well as our sales and internal teams. We also expect this to support our goal of maximizing our first pass claims approval with Medicare, an area we've already made significant progress over the last 18 months. As an update on Medicare, we continue to monitor the introduction and administration of the new Lymphedema Treatment Act. While we remain encouraged that it will bring more awareness and access for basic or conservative therapies, we continue to watch for any impact as the policies interpretation emerges among Medicare administrators. That said, while our own local coverage determination, or LCD, has been in place for many years for lymphedema pumps, we've seen some subtle changes in how Medicare administers the policy. Our own movement toward an e-prescribing tool is intended to even more efficiently pair the necessary documentation with their adjudication process, striving for more efficiency among all parties. In fact, our recently deployed pilot across a handful of regions is off to an encouraging start. This tool will make the order and prescribing process easier for HCPs while also positively impacting our sales force productivity given our reps and back office would need to spend less time gathering patient documentation. While broader deployment isn't expected until later in the year, we're excited about the impact it can have on our business in 2025. We also remain on track to introduce a new customer relationship management tool, or CRM, later this year. While we have an incredible amount of data, we know that optimizing it for our users can improve internal communication, sales productivity and ultimately growth. Among the benefits in mind, we expect to provide better visibility to both our sales and trainer teams so we can more efficiently assign and fulfill demos and trainings. A CRM, along with Kylee, is also expected to help us follow each patient's journey, ensuring we introduce the right progression of therapy based on their progress. Our sales force is excited about these new tools and the ability to ultimately advance customer orders faster. Our product development efforts continue to advance as well. Development on our next-generation lymphedema therapy platform remains on track for a late 2024 introduction. It's expected to bring a host of new lifestyle-friendly attributes to patients, even further improving the user experience and demonstrating our ongoing leadership in this space. We also continued to see patient uptake of our Kylee mobile application during the first quarter. At the end of the first quarter, we had over 26,000 unique user profiles registered in Kylee. Moreover, we saw almost 50,000 user check-ins during the quarter. As a reminder, the Kylee application provides direct access to education resources and tools for patients to track symptoms and their disease progression. We continue to believe Kylee is an important part of their therapy experience. Now a few updates on our clinical education and clinical evidence progress. On the heels of a record year for medical education in terms of patient and clinician engagement, we started 2024 off even stronger, reaching over 3,000 clinicians in the first quarter alone across our lymphedema and AffloVest product lines. Our first quarter medical education programming was specifically focused on lymphedema and bronchiectasis diagnosis, their comorbidities and available treatments. We also hosted a number of targeted CEU eligible education events for respiratory therapists focused on specific patient populations, including bronchiectasis, that drew over 200 attendees as well as training on detecting radiation fibrosis for oncology clinicians that attracted over 400 attendees. In addition to our progress on education, we continue to fortify the clinical evidence supporting the impact of our products on lymphedema patients. During the first quarter, we completed enrollment in our multicenter randomized control clinical trial evaluating Flexitouch Plus for the treatment of lymphedema among head and neck cancer survivors. With enrollment complete as of the end of last month with 235 patients, we now move to following these last patients for 6 months before tallying all of the results. As a reminder, this trial compares the effectiveness of Flexitouch versus standard of care over a 6-month duration. Outcome measures include both physical improvements as well as biosocial quality of life results. With over 400,000 oral cavity and pharynx cancer patients currently living in the United States and the majority likely to have or develop lymphedema, we remain committed to providing a more available path for those needing and seeking treatment. We're proud and enthusiastic about this trial so far as it represents the largest randomized clinical trial ever conducted among head and neck lymphedema patients. The study has 10 enrolling sites, including preeminent cancer institutions like Vanderbilt, Johns Hopkins and Rush University Medical Center. Given the 6-month patient follow-up period, we expect initial results from the trial to be available near the end of the year and look forward to sharing additional details with you once available. We were also pleased to see results from a new clinical study among VA patients published in the Journal of Vascular Surgery last month. The study of the foresight multicenter trial followed 179 veterans with lymphedema that were being treated with Flexitouch. This is the largest ever peer-reviewed prospective study among lymphedema patients using pneumatic compression therapy. Among the statistically significant findings, patients using Flexitouch therapy demonstrated improvements in quality of life as well as decreases in cellulitis events and limb girth and improvements in skin changes. Patients were evaluated at 4 intervals over 52 weeks. And while compliance to self MLD was well below 10% among subjects, it reflected 92% compliance with their Flexitouch at 4 weeks, and 72% remained compliant 5 to 7 days a week even after a full year of therapy. These results not only reinforce the clinical efficacy of Flexitouch on patients with varied disease levels but also underscore how the positive results patients experience with our therapies yield high compliance. Overall, I'm proud of the work our team accomplished surrounding all of our education and research initiatives. And I look forward to continuing to raise awareness at each of the payer, clinician and patient levels as we progress through the year. With that, Elaine will now review our first quarter financial results in more detail. Elaine?

Elaine Birkemeyer, CFO

Thanks, Dan. Unless noted otherwise, all references to first quarter financial results are on a GAAP and year-over-year basis. Total revenue in the first quarter increased $2.2 million or 3.8% to $61.1 million. By product line, sales and rentals of lymphedema products, which includes our Flexitouch and Entre systems, increased $2.6 million or 5.1% to $52.3 million. And sales of our airway clearance products, which includes our AffloVest system, decreased $319,000 or 3.5% to $8.8 million. Continuing down the P&L. Gross margin was 71.1% of revenue compared to 70.5% in the first quarter of 2023. Non-GAAP gross margin, which excludes noncash intangible amortization in both periods, was 71.6% compared to 71% in the prior year. The increase in non-GAAP gross margin was attributable to lower manufacturing and freight costs. First quarter operating expenses increased $1.1 million or 2.5% to $46.4 million. The change in GAAP operating expenses reflected a $1.1 million increase in sales and marketing expenses and a $0.8 million increase in reimbursement, general and administrative expenses. These items were partly offset by a $0.7 million decrease in noncash intangible asset amortization and earn-out expense. Operating loss decreased $0.8 million or 22.1% to $3 million. The decrease in operating loss was driven by a $2 million or 4.7% increase in our gross profit, offset by the aforementioned $1.1 million increase in operating expenses. Non-GAAP operating loss decreased $0.5 million or 22.3% to $1.7 million. As a reminder, our non-GAAP operating income excludes noncash intangible amortization and earn-out expense as well as certain nonrecurring operating expenses. We provided a detailed GAAP to non-GAAP reconciliation in our earnings press release. Other income net increased $1.1 million or 115.6% to $0.2 million. The increase was due to higher interest income and lower interest expense, primarily driven by the retirement of our revolving line of credit at the end of 2023. Income tax benefit decreased $2.3 million or 79.4% year-over-year to $0.6 million, driven primarily by a lower taxable loss. Net loss increased $0.3 million or 17% to $2.2 million or $0.09 per diluted share compared to $1.9 million or $0.09 per diluted share. Non-GAAP net loss increased $0.6 million or 87.6% to $1.3 million compared to $0.7 million. Adjusted EBITDA doubled to $1 million or 1.7% of sales compared to $0.5 million or 0.9% of sales. With respect to our balance sheet, we had $60.7 million in cash and cash equivalents and $28.5 million of outstanding borrowings at quarter end. This compares to $61 million in cash and $29.3 million of outstanding borrowings as of December 31, 2023. We are pleased to see our cash position remain relatively constant since the end of 2023. This is particularly noteworthy when considering the onetime impacts in Q1 from several cash outflow items, including $6.6 million related to our annual bonus payout. As Dan mentioned earlier, our team made significant progress this quarter with cash collections and working down our accounts receivable balance even further, both of which helped offset the onetime cash outflows as well as our strategic investments. Turning to a review of our 2024 outlook, which we reaffirmed in our earnings press release today. We continue to expect full year 2024 total revenue in the range of $300 million to $305 million, representing growth of approximately 9% to 11% year-over-year. As a reminder, our 2024 total revenue guidance range assumes that growth in both our lymphedema and airway clearance product lines will be in a similar range. For modeling purposes, for the full year 2024, we expect our GAAP gross margins to be up slightly as compared to prior year; our GAAP operating expenses to increase low double digits as we advance our tech-related investments throughout the year; interest income of approximately $0.4 million; a tax rate of 30%; and a fully diluted weighted average share count of approximately 24 million shares. We also continue to expect to generate adjusted EBITDA of approximately $33 million to $35 million in 2024. Our adjusted EBITDA expectation assumes certain noncash items, including stock compensation expense of approximately $8.3 million and tangible amortization of approximately $3.9 million and depreciation expense of approximately $3 million.

Daniel Reuvers, President and CEO

Thanks, Elaine. The first quarter was another opportunity for us to demonstrate continued progress across our key financial and operational priorities. I'm pleased with how the company is set up for further execution through 2024 and especially proud of the way our team continues to lead through change, all with the goal of delivering the best products and therapy possible for lymphedema and bronchiectasis patients. Before concluding our prepared remarks, I'd like to comment on the press release we issued on April 23, announcing my retirement as of the end of June and the appointment of Tactile Board member, Sheri Dodd, as the company's next Chief Executive Officer effective July 1. Sheri has an extensive track record as a healthcare industry veteran, having served in leadership roles across companies such as Medtronic and Johnson & Johnson, where she focused specifically on the chronic care space and developed health economics and reimbursement expertise. She's also developed a deep familiarity with our business through her service as a member of our Board of Directors since 2021. As a Board member, she's contributed a thoughtful perspective to our current direction, and her experience will undoubtedly enable her to quickly focus on advancing strategies to drive Tactile's next phase of growth. I'm excited to welcome her to our new operating role and look forward to working with her to ensure a smooth, uninterrupted transition. Personally, I'm excited about my next chapter, including more time with my family. But I'll remain as an adviser to Sheri following our transition as well as continuing to serve on our Board of Directors. Indeed, I remain heavily invested in the ongoing success of Tactile Medical, and my interests remain aligned in delivering shareholder value. Stepping back, I'm proud of what we've achieved during my tenure at Tactile. We refreshed our best-in-class product portfolio across the pneumatic compression segment, added HFCWO vest therapy to treat bronchiectasis, advanced clinical evidence and served thousands of new patients in both segments. We also assembled a world-class leadership team, strengthened our balance sheet and have delivered solid growth in both revenue and profitability. Our progress and momentum underscore my confidence in Tactile's future. I believe the company is well positioned and on track for delivering consistent, sustainable and profitable growth in 2024 and beyond. We have clear and actionable initiatives in place to help fuel this growth and the right leaders in the right seats to execute it. I'd also like to take this opportunity to thank the Tactile team. It's been humbling to attract such capable talent across the organization, and the passion they bring to our mission every day is inspiring. I'm certain they'll continue to deliver for patients and shareholders. And with that, operator, we'll now open the call for questions.

Operator, Operator

Our first question will come from Adam Maeder with Piper Sandler.

Adam Maeder, Analyst

Congrats on the nice start to the year. And Dan, it's been a pleasure. Certainly wishing you well in retirement. I wanted to start on the modeling side for you, Elaine or Dan. But I wanted to ask about phasing of quarterly revenue for the rest of the year. And for Q2 specifically, I show consensus at about $73 million which is, I think, close to a 20% increase sequentially quarter-over-quarter. So wondering if you have any comment to the phasing of revenue on the top line. And then a similar question as it relates to adjusted EBITDA. I know margins in Q1 are seasonally weaker, but just help us kind of bridge to that $33 million to $35 million guidance for the full year '24. And then I have a follow-up.

Daniel Reuvers, President and CEO

Yes. Thanks, Adam, for the questions. I'll take a shot at the beginning and let Elaine kind of clean up on this one. But I'd say that we continue to provide as we're happy to reinforce our guidance for the full year. I'm not going to necessarily provide quarterly guidance, but I think it's fair to expect some modest improvements in growth in both our pneumatic compression as well as in the AffloVest category as well. So as is typical, you'd typically see some ramp into the second quarter and sequential improvements in revenue each of the next 3. So I don't think anything terribly out of the ordinary in some of the kind of step-up that we've seen in the past. I think you had a question about operating income as well. I think I'll let Elaine take that one.

Elaine Birkemeyer, CFO

Yes. I think as you mentioned, our first quarter, we're always the leanest in terms of profitability. So this followed a very similar pattern, but we were pleased to see that adjusted EBITDA did double from a year-over-year perspective. And as in years past, that adjusted EBITDA margin does continue to build.

Daniel Reuvers, President and CEO

Yes. Typically, the back half is where we end up realizing the majority of our operating contribution. It's been that way for the last few years. I think we were just happy to be able to see a healthy positive number in the first quarter, which hasn't always been the case.

Adam Maeder, Analyst

Yes. Good color there, guys. And for the follow-up, I wanted to ask about head and neck. I guess a multipart question here. First, can you just remind us the key objective for that trial? I believe it's to develop clinical evidence to support payer coverage, but wanted to confirm that. And then when should we think about a potential contribution or impact commercially to your business? Assuming a positive trial, is that beginning in 2025, back half of 2025? Presumably, there's some blocking and tackling with payers. And lastly, would you expect this to be a Tactile specific benefit? Or would this lift the entire lymphedema category for head and neck?

Daniel Reuvers, President and CEO

Yes. Thanks for the question. Just to remind, there's about over 400,000 head and neck lymphedema patients or survivors in the United States. Evidence points to about 90% of them have or will develop lymphedema. The study that we just completed enrollment on 235 patients, which is about 10 times as big as the pilot study we did a few years ago with really compelling results. We knew that a bigger N was likely going to be necessary to persuade the right audiences. And when you talk about who's the end market for this data, it's really threefold. Certainly, the first one is the payer. We want to make sure that we're demonstrating the kind of evidence that we think that a study like this can that make sure that availability for patients becomes more readily accessible. We think that compelling outcomes should also influence HCPs, and the ability to ensure that they're screening for lymphedema and treating it when presented is an important step, where it's not necessarily commonplace in an awful lot of practices, even in some really well-regarded cancer facilities. And then certainly, I think the patient awareness can benefit from this one as well. I think from a contribution standpoint, there's a 6-month follow-up after the last patient in, which was just about the end of April. So we have to go ahead and fulfill that period, and then we can start to see the data assembled and turned into some kind of a manuscript that can be made publicly available and either presented and/or published. It's probably a back half 2025 contributor, but we ultimately believe that this one will have a material impact, I think, on our business. And I think the last part of your question is a particularly encouraging one. While sometimes rising tides lift all boats, this is one that we think we'll particularly benefit from because we actually shared a year or so ago we got some new IP issued that really ring-fenced that part of the body. So any compression, pneumatic or otherwise, that treats the head and neck region of the body, we feel like we've really got that space protected. So this was an investment in helping more patients but also one that we think we will uniquely benefit from.

Operator, Operator

Our next question comes from the line of Margaret Kaczor with William Blair.

Margaret Kaczor, Analyst

I guess just to start, it's partly a guidance question, partly a growth outlook question. But how do you get to the high end, low end of the guide? And I want to focus maybe a little bit more on lymphedema. How should we think about the cadence of impact for the new sales reps that you hired? Obviously, not a huge impact this quarter, maybe not huge next quarter. But as we get towards the second half of the year, is that the right timing or further out? And just in general, as we think about the catalyst for lymphedema, how does this get to be that sustainable low double-digit plus growth? I don't know if you can point to touchpoints to clinicians, what's the relative number of that 3,000 new products, et cetera. Just trying to frame that up a little bit.

Elaine Birkemeyer, CFO

Thank you for the question. We identified several growth drivers and are pleased with the progress we've made. All of these drivers will contribute to sales growth over time. It won't be an immediate large increase, but to reiterate, we added some sales representatives in Q4, with a larger addition in Q1. We plan to add a bit more in the second half of the year, with those new hires expected to be fully effective as the year advances. We're also making progress in transitioning our in-home demonstrations to our trainers, which is freeing up more time for our sales representatives. Our technology roadmap is progressing well; we have piloted an e-prescribing tool and will launch a CRM later this year, both of which will help build momentum as the year continues. While I know you want to focus on lymphedema, we also expect to see a recovery in the AffloVest business in the latter half of the year.

Margaret Kaczor, Analyst

And I'm going to push the second time on the question. And again, maybe just my more simplistic mindset. But if you're growing your sales reps 9%, and realistically, I would assume revenue growth should grow at least 9%, especially as you highlight these time efficiencies and other efficiencies within the system to try to accelerate that more. So am I understanding that correctly and that's kind of how you bridge to that double-digit growth?

Daniel Reuvers, President and CEO

Yes. I think that's right, Margaret. I mean when you think about the fact that, yes, we're adding reps, but we know that typically it takes a couple of quarters for their productivity to kick in once they get fully trained. So it's really a back half kind of contribution item. And then the productivity piece that we really benefited from last year, which was starting to get the patient trainers to take some of these in-home demos, our goal is to actually continue to expand that in the back half, which should give us some additional productivity gains on top of a bigger head count. And I think we know we had the toughest comp in Q1. So yes, I think if you look at the guidance that we reaffirmed, clearly, we're going to have to do better in the back half. So all of those assumptions are embedded in that.

Margaret Kaczor, Analyst

Okay. That's helpful. Best of luck in retirement. I think we're all jealous on the call here for your future. Maybe just last one. As we look at the adjusted EBITDA guide, that remained unchanged despite what seemed like a great quarter. You've increased your guidance a little bit in gross margin. You clearly outlined a variety of drivers to see margin expansion. So I'm just trying to get a sense. Is that conservatism? Are you spending some of that upside on other OpEx items as you think about guidance throughout the year?

Elaine Birkemeyer, CFO

Yes. So firstly, I think it's still early in the year. So kind of the rationale for not changing the adjusted EBITDA guidance. But I think also, as we think back to our last call, we talked a lot about this being an investment year, and that continues to prove true. And we do continue to expect to see leverage and productivity, but we will be reinvesting some of that savings to help fund our technology road map as well as the additional hires that we made in this first half.

Operator, Operator

Our next question comes from the line of Suraj Kalia with Oppenheimer & Co.

Suraj Kalia, Analyst

Dan, Elaine, can you hear me all right?

Elaine Birkemeyer, CFO

We can.

Suraj Kalia, Analyst

Perfect. First and foremost, Dan, it's been a pleasure working with you all these years. Wish you are very healthy and enjoyable retirement. Dan, just following up on the head and neck line of questioning. So if memory serves me right, in the pilot study, patients are required twice a day to use a pneumatic compression. I guess is the protocol the same in the pivotal study? And also, if I could follow up on a subpart of this question. There are different measures for inflammation and swelling, I believe, at CT, digital photography and grading and endoscopy and whatnot. Can you help us understand that? How do you reconcile a difference between readings for the same patient using 2 different methodologies?

Daniel Reuvers, President and CEO

Yes. First of all, the protocols are not identical to those in the pilot study. However, the encouraging results from the pilot led us to consider this a responsible investment that the market requires, especially with a larger sample size and utilizing pneumatic compression for treatment. Quality of life factors are definitely included, along with changes in skin swelling and others, all of which will be considered in the study's outcome metrics.

Suraj Kalia, Analyst

Got it. Okay. In terms of the next-gen Flexitouch, Dan, can you give us a sneak peek regarding the upgrades? Is it primarily related to the form factor, or are you considering changes to the algorithm, such as the duration for pneumatic compression or possibly higher pressure? How should we think about the next-gen system later this year and into next year?

Daniel Reuvers, President and CEO

Yes. Sure, Suraj. First, it's not necessarily a next-gen Flexitouch. What we said is a next-gen pneumatic compression device. And the attributes that we've been focused on are trying to make this a much more patient-friendly experience. We know this is a lifestyle that the patient has to follow. They're using and depending on this therapy literally daily for the most part for life. And we want to make sure that it integrates more seamlessly. So there's what I would call a host of consumer-friendly attributes. We're being a little bit cautious about some of the details until the product is closer to launch. But yes, I think that the components that we've assembled, we're quite enthusiastic about what kind of reception we can get from our customers.

Suraj Kalia, Analyst

Fair enough. Dan, for my final question, I believe I heard in the prepared remarks that home training has increased from 30% to 35% by the trainers, allowing the sales team more bandwidth. Additionally, VA and commercial have experienced significant growth. How should we quantitatively interpret the correlation between the increased bandwidth over time for the existing 250 or so sales representatives in the lymphedema sector of the business?

Daniel Reuvers, President and CEO

Sure, Suraj. That's a great question. Last year, we saw a 14% growth in lymphedema without increasing our headcount, which reflects the increased productivity we achieve by allowing our sales team more selling time. In the first quarter, our patient education coordinators reached 35%, and we aim to increase that to 50% by the end of the year. This change should help our sales team spend more time in high-volume clinics rather than on home visits. Additionally, we have not needed to hire as many patient trainers to accommodate this growth because the existing trainers provide thorough demonstrations, reducing the need for in-home trainings after the device is shipped. It’s important to note that we are required to conduct a presales demonstration for Medicare patients, and many patients can effectively start using their therapy right away with the quick start guide and online resources due to the comprehensive nature of these demos. When a trainer excels in the presales demonstration, it minimizes the need for post-sales training, thereby allowing us to maximize capacity with our current team.

Operator, Operator

Thank you. We are currently seeing no remaining questions at this time. That does conclude our conference for today. Thank you for your participation.